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DEALING WITH
TRAUMA:
A TF-CBT
WORKBOOK FOR
TEENS
By Alison Hendricks, Judith A. Cohen, Anthony
P. Mannarino, and Esther Deblinger
For personal/clinical use only. Please do not distribute for
other purposes without written permission from the authors.
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DEALING WITH TRAUMA: A TF-CBT WORKBOOK FOR
TEENS
TABLE OF CONTENTS
INTRODUCTION 3-4
WELCOME TO THERAPY 5
ABOUT YOU 6
ABOUT YOUR FAMILY 7
LEARNING ABOUT TRAUMATIC EVENTS 8
HOW DO TEENS FEEL AFTER TRAUMA? 9
WHAT IS RELAXATION? 10
HOMEWORK: LET’S RELAX 11
DEEP BREATHING 12
YOUR SAFE PLACE 13
ABOUT FEELINGS 14
EXPERIENCING FEELINGS IN YOUR BODY 15
FACIAL EXPRESSIONS 16
HOW STRONG OR INTENSE ARE YOUR FEELINGS? 17
COPING WITH UPSETTING FEELINGS 18
FEELINGS SURVIVAL KIT 19
STOP THAT THOUGHT! 20
THOUGHTS, FEELINGS, AND … ACTION 21
THOUGHTS MATTER 22
THOUGHT PROBLEMS 23
NOTICE YOUR THOUGHTS 24
TELLING YOUR STORY 25
YOUR STORY 26
FEELINGS 1-10 27
YOUR THOUGHTS AND FEELINGS ABOUT THE TRAUMA(S) 28
BATTLING TRAUMA REMINDERS 29
SHARING YOUR STORY 30
BEING SAFE 31
YOUR CIRCLE OF SAFETY 32
YOUR FABULOUS FUTURE 33
LET’S REVIEW 34
SAYING GOOD-BYE 35
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DEALING WITH TRAUMA: A TF-CBT WORKBOOK FOR TEENS
Introduction
This workbook has been developed for use with teenagers who
experienced one or more
traumatic events. The activities in the workbook correspond to
the treatment components
of the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
model, which was
developed by Judith Cohen, Anthony Mannarino, and Esther
Deblinger (Cohen,
Mannarino, & Deblinger, 2006). The intended use of the
workbook is by master’s level
mental health professionals who have also had training in TF-CBT
and have read the
manual on TF-CBT (cited above).
The workbook was created as a supplemental resource to assist
therapists as they work
through each component of the TF-CBT model with their clients.
This workbook is one
of the many resources that therapists can use in implementing
TF-CBT, and the manual
cited above provides and extensive list of books, activities,
and other therapeutic aids.
The workbook intends to provide a helpful framework to cover
each component of TF-
CBT, but other resources and activities should also be utilized
as clinically indicated (i.e.,
role plays, movement therapy, audio relaxation exercises,
therapeutic board games,
music, etc). Get creative! As always, clinical judgment takes
precedence. Some of the
activities included in the workbook may not be appropriate for
all teens, and flexibility
needs to be balanced with fidelity to the treatment model.
The workbook activities were developed for implementing the
PRACTICE components
of the TF-CBT model: Psycho-education, Relaxation, Affective
regulation and
modulation, Cognitive coping and processing, Trauma narrative
and cognitive processing
of the traumatic experience(s), In vivo mastery of trauma
reminders, Conjoint sessions,
and Enhancing future safety and development. The teen and parent
will initially need
some orientation to TF-CBT, and issues of confidentiality and
sharing of the teen’s work
need to be discussed from the outset. The workbook can be
completed over the course of
12-20 weeks, depending on the length of each session and the
individual circumstances of
the teen and family. Keep in mind that some traumatized
adolescents may require other
types of treatment before, during, or after TF-CBT. The workbook
activities correspond
to the components of the TF-CBT model as follows:
Orientation to Therapy and TF-CBT, Engagement Pages 5-7
Psycho-education on Trauma and Reactions to Trauma Pages 8-9
Relaxation, Progressive Muscle Relaxation, Deep Breathing Pages
10-12
Positive Imagery Page 13
Feelings Identification Pages 14-16
Feelings Ratings and Affect Modulation Pages 17-19
Thought Stopping Page 20
Cognitive Processing Pages 21-24
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Creating the Trauma Narrative Pages 25-27
Processing the Traumatic Experience(s) Page 28
In Vivo Mastery of Trauma Reminders Page 29
Conjoint Session – Sharing the Trauma Narrative Page 30
Conjoint Session – Enhancing Future Safety and Development Pages
31-32
Goals, Review, Graduation Pages 33-35
Following the structure of the TF-CBT model, the therapist meets
individually with the
teen each week to complete the above (and other supplemental)
treatment activities.
Then the therapist meets with the parent individually to work
with the caretaker on the
same component, to teach him/her the skills to support the teen
at home and for the
caretaker to process his/her own feelings about the trauma.
Sharing the activities
completed by the teen in the workbook can be a helpful way to
work with the parent on
the treatment components, in addition to supplemental resources
geared toward parents.
Parents usually appreciate seeing their adolescent’s artwork and
writing, and sharing
these provides the opportunity for the therapist to increase the
parent’s empathy and
understanding of the teen’s experience. Use your clinical
judgment if the teen does not
want you to share a particular page with a parent right away or
if sharing is contra-
indicated in any way. Some games or activities may be used
during conjoint sessions in
which the teen and parent can practice and share together. For
example, teens may enjoy
teaching their caretaker the relaxation games (Page 8) or the
Feelings Charades game
(Page 12) and playing together in session. It is important to
have caretakers involved in
the safety component (Pages 27-28). Again, flexibility is
important!
Homework activities can be assigned each week for the teen,
caretaker, or dyad at the
discretion of the therapist. The workbook includes a relaxation
activity that is labeled as
homework (it can also be taught or practiced in session) and
recommends daily practice
of the deep breathing techniques. You may create games for the
dyad to play as
homework, assign thought logs, etc. Use your imagination, and
tap into the individual
teen’s strengths and interests when planning your
interventions.
For further information on TF-CBT and its components, please
refer to the treatment
manual:
Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006).
Treating trauma and traumatic
grief in children and adolescents. New York: Guilford Press.
An additional resource is the on-line TF-CBT training at:
http://tfcbt.musc.edu/.
http://tfcbt.musc.edu/
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WELCOME TO THERAPY
Therapy is a safe place to help you feel better about
upsetting
or confusing events that you have experienced. You will get
to
draw, write, and talk in therapy. You will learn many
important
things about: upsetting/confusing events, feelings,
relaxation,
and how to stay safe. You will also learn a lot about
yourself:
your thoughts, feelings, behaviors, and strengths. Please
write
about or draw a picture to show how you feel about being
here
today:
Do you have any questions about therapy?
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ABOUT YOU
You are a very special and unique person. There are many
special things about you and a lot of things you are good
at.
Please draw or write some of these things:
What are some things you like to do for fun?
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ABOUT YOUR FAMILY
Who do you live with? Who is in your family? What are some
things
you like about your family? What do you and your family like to
do
together? Please draw or write some of these things:
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LEARNING ABOUT TRAUMATIC EVENTS
Upsetting/confusing events are also called traumas. Traumatic
events can
cause people to feel very afraid, upset, confused, helpless,
angry, empty or
numb. There are different kinds of traumas. Let’s learn about
the traumatic
event(s) that you experienced. Your therapist will help you
answer some
common questions teens have about traumatic experiences. If you
have
experienced more than one type of trauma, your therapist will
talk to you about
how to understand these experiences.
What is it called?
What does that mean?
Who does this happen to?
Do a lot of teens experience this?
Why does this happen?
What can teens do if this happens to them?
Create your own questions here:
1.
2.
3.
4.
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HOW DO TEENS FEEL AFTER TRAUMA?
Many teens have scary memories or dreams about trauma. Some
teens
also feel jumpy or nervous or angry. After trauma, a lot of
teens watch
out for danger and worry about bad things happening. Some teens
also
have trouble sleeping and paying attention in school. A lot of
teens feel
like they DON’T want to talk about or think about the trauma(s),
but
trauma memories pop into their minds anyway. When something
reminds them of the trauma(s), teens may feel upset and may have
strong
reactions in their bodies (heart beating fast, stomach ache).
Other teens
may feel empty and numb, like they can’t feel anything at all.
They may
use drugs or alcohol to try to deal with upsetting feelings.
Please circle any of the things above that you have experienced
since the
trauma (s). Then draw or write below what kinds of feelings you
think
teens have after these kinds of experiences:
What can teens do about these feelings?
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WHAT IS RELAXATION?
Relaxation is about feeling calm and peaceful. After traumas
happen, we
often feel tense, jumpy, and worried. We feel better when we
learn to
relax our bodies and minds! This exercise teaches us how to
relax using
our muscles:
Sit comfortably in your chair with your arms at your sides and
your feet planted on the
floor. Close your eyes or look down at the ground while you do
this exercise. Imagine
that you have a ball of clay in your right hand. Squeeze that
ball of clay as hard as you
can! While you are squeezing, feel how tight the muscles of your
hand and arm are.
Count to five as you squeeze, then drop the ball of clay and let
your hand hang loose.
Feel the difference in the muscles of your hand and arm when
they are relaxed. Repeat
to yourself, “My hand is relaxed.” Now do the same thing with
your left hand. You can
do this with all the parts of your body one at a time or all at
the same time (your
therapist will help you)! Which way would you like to do it?
Don’t forget to include all
your muscle groups (arms, feet, legs, stomach, back, chest,
shoulders, face).
Please draw two pictures of yourself below:
Tense/Tight/Stressed Relaxed
What are some things you do that help you feel relaxed?
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HOMEWORK: LET’S RELAX
Many teens have trouble calming down or falling asleep at
night. If this ever happens to you, practice this activity
at
home. A family member or friend can read it to you before
bedtime or any other time when you want to relax.
Lie down or sit comfortably somewhere quiet and cozy (your
bed, a couch). Breathe in slowly and out even more slowly.
Close your eyes and imagine you are floating on a soft,
fluffy
cloud. You feel very safe on your cloud as it cradles your
body
like a hammock. Your whole body feels very relaxed and
heavy. Notice your feet. Your feet feel very relaxed. Your
feet
feel so heavy that it would be hard to lift them if you
tried.
Now notice your legs. Your legs feel very relaxed. Your legs
feel so comfortable all nestled into your cloud. That nice,
warm, relaxed feeling is slowly traveling up your body, filling
it
with peace. Notice your stomach. It feels very calm and
filled
with a pleasant warmth. Now be aware of your chest. Your
chest feels relaxed as it moves up and down slowly with each
breath. Notice your neck and shoulders. They feel so
tranquil
and heavy. Feel the backs of your shoulders touching the
cloud below you, sinking in gently. Feel how relaxed your
head is right now. It feels very warm, pleasant, and heavy.
Your head and face are very relaxed. Your mouth and eyes are
free of stress. Allow your thoughts to come and go without
worrying about anything. Everything is okay, and you are
feeling very calm and good. Enjoy the warm, calming
sensation as it travels all around your body, filling you
with
peace and relaxation.
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DEEP BREATHING
Sometimes when we are upset, we forget to breathe. Or we
take short, shallow breaths (like a puppy dog panting) that
don’t give our bodies the oxygen we need. To help ourselves
feel relaxed and calm, we can practice deep breathing.
Deep breathing is when you breathe in slowly and deeply
(counting to 5 in your head) as your lungs fill up with air
(you
can watch your belly stick out as you breathe in). Then you
let
the air out, EVEN SLOWER (count to 6) and watch your belly
go
back in as the air is slowly pushed out. Pay attention to the
air
as it moves in and out of your body as you count.
Fun games with deep breathing:
1. Breathe out to empty the air out of your lungs. Breathe in
deeply and
evenly through both nostrils. Hold your breath for a count of
five. Use
your left thumb to block off your left nostril and breathe out
slowly
through your right nostril. Breathe in deeply through your right
nostril
and hold your breath for five counts. Now block your right
nostril with
your right thumb and breathe out slowly through your left
nostril. Repeat
several times.
2. Put on some slow, relaxing music. Close your eyes and listen
to the
beat. Take a deep breath in for 3-5 beats of the music, hold
your breath
for 3-5 beats, and then breathe out slowly for 3-5 beats.
Repeat, pairing
your breathing with the music.
Teach these games to someone you care about and practice at
home (at least once a day).
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YOUR SAFE PLACE
Please close your eyes (or look down) and take a few minutes to
think
about a place (real or imaginary) where you feel very safe,
calm, and
happy. You can tell your therapist once you have your safe place
in mind.
Now draw a picture or write about your safe place below. Add as
many
details as you can to show what you see, hear, smell, taste, and
feel when
you are in your safe place.
You can close your eyes and imagine you are in your safe place
when you
feel scared or tense. When you think about your safe place,
remember all
the details that you drew in this picture.
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ABOUT FEELINGS
Feelings are what we feel in our bodies and hearts. There
are
many different feelings that we have, and our feelings may
change from moment to moment. Sometimes we even feel two
or more feelings at the same time.
Please write down as many feelings as you can think of below
on the left side of this paper:
Great! Now put a color next to each feeling to describe the
feeling.
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EXPERIENCING FEELINGS IN YOUR BODY
Remember the feelings and colors you listed on Page 14? We’re
going to
use those colors now to show where in your body you experience
each
feeling. You don’t have to do all the feelings you listed; you
and your
therapist can choose which feelings you want to include. For
each feeling
you choose, close your eyes and imagine having that feeling
right now.
Where do you experience that feeling in your body? Please color
in the
places on your body where you experience each feeling and tell
your
therapist what it feels like.
Our bodies tell us how we are feeling.
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FACIAL EXPRESSIONS
A good way to tell how we feel and how others feel is by
noticing facial
expressions. Please draw the feelings in the circles to show how
we
express our feelings on our faces (the last two are blank for
you to draw
any feelings you want):
happy sad angry
scared nervous excited
confused shocked brave
proud
How do you feel right now? You can play a game with your
therapist called
“Feelings Charades.” Take turns acting out the above feelings;
the other person
tries to guess which feeling you are acting out. Then you get to
tell what makes
you feel that way. You can also play this game at home or with
your friends.
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HOW STRONG OR INTENSE ARE YOUR FEELINGS?
Sometimes we feel a feeling just a little bit, and other times
we feel a
feeling so strongly that we feel like we might BURST with that
feeling.
You can rate or measure your feelings, just like a thermometer
measures
temperature. The number tells how intense the feeling is.
What feelings are you having right now? How would you rate
each of those feelings (on a scale of 1-10)?
10 VERY STRONG
9
8 A LOT
7
6
5 MEDIUM
4
3
2 A LITTLE
1
0 NOT AT ALL
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COPING WITH UPSETTING FEELINGS
When we experience an upsetting feeling very strongly, we
can
DO THINGS to lessen the intensity of the feeling. For
example,
if your anger is at a 10 (very strong), you can do things to
bring it down to a 1 or 2. What are some of these things you
can do? Please draw a picture of you doing something that
would help bring your anger down:
YOU’RE IN CHARGE OF YOUR FEELINGS.
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FEELINGS SURVIVAL KIT
When you feel very sad, scared, mad, or worried, what are
some things you can do to feel better? What are some things
you can tell yourself that would make you feel better?
Please
make a list of things you can do and say to feel better:
Congratulations! You have just made your own personal
Feelings Survival Kit. You can cut out the items from your
list and place them in a special box, bag, or toolkit. Take
it
with you so that the next time you feel very upset you will
remember what to do.
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STOP THAT THOUGHT!
Sometimes we think about bad things over and over (like a song
you
don’t like that gets stuck in your head). We’ll call this a bad
song,
because it can make us feel really bad! But guess what? You can
stop
that bad song! All you have to do is notice when that bad song
plays in
your head. As soon as you hear it, press STOP! You can also say,
“Go
away, bad song!” And then you can sing yourself a happy song
(one
that makes you feel good)!
How does your bad song go? You can write or draw your bad song
here:
How does your happy song go? Write some of the words or draw
a
picture of your happy song here:
Let’s practice! Sing your bad song right now in your head. When
I say
STOP, start singing your happy song instead. Now you can decide
when
to press STOP on your bad song and PLAY your happy song!
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THOUGHTS, FEELINGS, AND… ACTION
What are thoughts? Thoughts are the ideas we have in our heads
(what
our brains tell us). Sometimes we say things to ourselves in our
heads
(not out loud), and these are also thoughts. For example, you
might
think, “I did a great job on my homework.” Can you think of some
other
thoughts?
What are feelings? Feelings are the emotions and sensations we
have in
our bodies and hearts (you already know a lot about feelings!).
What are
some feelings you know about?
What are actions? Actions are the things we do with our bodies!
For
example, we walk, dance, talk, draw, laugh, cry, etc. Can you
name some
other actions?
Thoughts, Feelings, and Actions Game
This is a game to help you learn the difference between
thoughts,
feelings, and actions. Put a blue X the items that are thoughts.
Put a
green X next to the items that are feelings. Put a red X next to
items that
are actions.
HAPPY SINGING
RUNNING LONELY
I’M SMART! SHE’S MAD AT ME
HITTING EATING ICE CREAM
THEY DON’T LIKE ME TAKING A WALK
SAD EXCITED
PLAYING I’LL BE OK
MAD SCARED
I CAN DO IT! TAKING A DEEP BREATH
IT’S MY FAULT HOPPING ON ONE FOOT
WORRIED BRAVE
HIDING TALKING TO A FRIEND
CRYING SAFE
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THOUGHTS MATTER
Our thoughts affect the way we feel and how we act. When
something
happens, we form thoughts about the event that lead to feelings
and
actions. The way we talk to ourselves in our heads also affects
how we
feel and what we do.
Thoughts Behavior
Feelings
Let’s look at your thoughts and how they make you feel and act.
List
three different thoughts you had today (or recently), how each
thought
made you feel, and what you did.
Thought Feeling What You Did
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THOUGHT PROBLEMS
Sometimes we all have thoughts that either aren’t true or don’t
help us to
feel better or solve problems. Some of these thought problems
involve
thinking that everything has to be all or nothing (i.e. “One
person made
fun of me, so that means everyone hates me”). Other thought
problems
focus on the worst possible outcome (i.e. “If my mom goes out,
I’m sure
something terrible is going to happen to her”). We sometimes get
stuck
in negative thinking (i.e. “Nothing ever works out for me” or
“I’ll never
feel OK again”). Please write or draw some problem thoughts that
you’ve
had recently.
How did these thoughts make you feel?
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NOTICE YOUR THOUGHTS
When you feel bad, what are you saying to yourself in your head?
It’s
probably the thought that’s making you feel bad. But guess what?
If you
practice, you can change your thoughts! Try doing this below.
First write
a thought that makes you feel bad and write down the feeling it
causes.
Then write a different thought that would make you feel better
and write
down the new feeling.
What actions might you take in the first situation? What about
in the
second situation? Do these actions lead to different results?
Which
results work out better for you?
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TELLING YOUR STORY
You’ve learned a lot so far about upsetting/confusing events,
feelings,
coping, relaxation, and thoughts. These are all important things
that will
help you as you begin to tell about the upsetting/confusing
event(s) that
happened to you. You get to decide where you want to start and
how you
would like to tell your story (you and your therapist can talk
about all the
different ways for kids to tell their stories). As you’re
telling about what
happened to you, your therapist will help you check in on your
feelings
(using the “Feelings 1-10” worksheet on Page 23). If you start
feeling
strongly upset, you can stop, and your therapist will help
remind you of
ways to manage your feelings. Remember - you’re in charge.
Please
draw or write below to describe how you feel about starting your
story.
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YOUR STORY
Now it’s time for you to decide how you would like to tell your
story.
Some teens like to write their own book, while other teens like
to express
what happened using poetry, songs, cartoon strips, puppet
shows,
radio/talk shows, etc. You and your therapist can talk about
creative
ways to tell about the traumatic event(s) that happened to you.
You get
to decide what form you want your story to take. Don’t forget to
use the
“Feelings 1-10” worksheet (on the next page) for each
session.
The title of my story is:
This is how I will create my story:
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FEELINGS 1-10
Remember when you used the thermometer to measure your
feelings
back on Page 17? Each time you meet with your therapist to tell
your
story, you will name and rate your feelings at the beginning,
middle, and
end of the session on this paper (make 1 copy of this worksheet
for every
trauma story session). Please rate your feelings on a scale of
1-10 to
describe the intensity of the feeling (1=a little bit, 5=medium,
10=very
strong, etc.). You and your therapist will then come up with a
plan to
help you manage any difficult feelings that may come up
between
sessions (don’t forget to use your Feelings Survival Kit).
Date:
Status Feeling(s) Rating
Beginning of Session
Middle of Session
End of Session
Self-Care Plan:
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YOUR THOUGHTS AND FEELINGS ABOUT THE
TRAUMA(S)
Remember how we learned that our thoughts are important? Your
thoughts related to
the trauma affect how you feel. These thoughts can help you feel
better more quickly,
or they can keep you feeling upset. Let’s look at some of your
thoughts related to the
trauma. Below is a list of questions and thoughts that kids
often have after an
upsetting/confusing event. You and your therapist can choose
which questions you will
discuss, and you can add your own questions or thoughts at the
end of the list. Then,
for each question, you can write down the answer that is most
helpful.
1. Why did this happen to me?
2. Who is responsible for the trauma(s)?
3. How will the trauma(s) affect me in the future?
4. How has trauma affected my family?
5. Since the trauma(s), my view of the world has changed in
these ways:
6. Since the trauma(s), my view of myself has changed in these
ways:
7. Since coming to therapy, I have learned these things about
myself:
8. Coming to therapy has changed me and my family in these
ways:
7. If I had a friend that went through a similar trauma, I would
give him or
her this advice:
9. If my friend thought that talking about trauma would be too
hard, I would
tell him or her:
10.
11.
12.
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BATTLING TRAUMA REMINDERS
Now that you have bravely told your story and talked about your
thoughts
and feelings, let’s talk about trauma reminders. Trauma
reminders are
things that remind you about the trauma(s). They can include
certain
places, people, words, sounds, smells, sensations, etc. When
you
experience these reminders, you may feel unsafe or as if you
were living
through the trauma(s) over again. But you can use your coping
and
relaxation skills to gain control over these pesky reminders.
Please draw
or write a few of your trauma reminders below.
Now you and your therapist will come up with a battle plan to
conquer
each trauma reminder, one by one. Then you can practice in
session to
gain control over these trauma reminders in your life.
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SHARING YOUR STORY
Great job! You did it! You have been very brave in telling your
story and
talking about your thoughts and feelings. It can help to share
your story
or to talk about the trauma(s) with someone you trust. How would
you
feel about sharing your story with a special someone? Please
draw a
picture or write about sharing your story or talking about the
trauma(s)
with your trusted person.
What are some questions you would like to ask your trusted
person? These can
be questions you have about the trauma(s) or a quiz to test how
much your
special person remembers (about your story, what you have
learned in therapy,
etc.).
1.
2.
3.
4.
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BEING SAFE
We do a lot of things every day to keep ourselves safe. What are
some
new things you’ve learned about safety since coming to therapy?
Please
draw a picture of you doing something to keep yourself safe.
What are some things other people can do to help keep you
safe?
1.
2.
3.
4.
5.
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YOUR CIRCLE OF SAFETY
There are a lot of people who care about you and your safety.
These are
people you can go to if you need help or if you want someone to
talk to.
Please draw a picture of yourself on the middle of this page.
Then create
your circle of safety by drawing and/or writing the names of all
the
people who help keep you safe around you. You can include their
phone
numbers, too.
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YOUR FABULOUS FUTURE
What hopes, dreams, and goals do you have for your future?
Please draw or write some of them in the space below.
You can achieve anything you set your mind to.
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34
LET’S REVIEW
What have you learned in therapy? What was your favorite
part? What was your least favorite part? Please write or draw
a
picture to show a special memory or lesson you want to take
with you from therapy.
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SAYING GOOD-BYE
How do you feel about saying good-bye? How do you feel
about graduating? You can use this final page to show all
the
feelings you’re having right now, using words, art, etc., OR
you
can draw a picture of you and your therapist saying
good-bye.
Congratulations on all your hard work! You did it! You
finished your book!